Healthcare Provider Details

I. General information

NPI: 1326540147
Provider Name (Legal Business Name): FRIENDS ARE FAMILY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PIONEER TRL
HANNIBAL MO
63401-2743
US

IV. Provider business mailing address

58 PIONEER TRL
HANNIBAL MO
63401-2743
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-6437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1679792964
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: KEVIN LIONBERGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-248-4494